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Liver issues for the Rhuematologist. David Wong, MD University of Toronto www.torontoliver.ca. Disclosures (last 1 year): Research Studies: BMS, Gilead, Johnson & Johnson, Vertex Advisory Boards: Merck, Vertex. Objectives.

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liver issues for the rhuematologist

Liver issues for the Rhuematologist

David Wong, MD

University of Toronto

www.torontoliver.ca

Disclosures (last 1 year):

Research Studies: BMS, Gilead, Johnson & Johnson, Vertex

Advisory Boards: Merck, Vertex

objectives
Objectives

To understand the sensitivity and specificity of Fibroscan and Fibrotest for liver monitoring in patients receiving MTX

To understand which patients to refer to a specialist

To consider which labs to monitor when screening for liver problems with DMARDS

liver function the liver is not a filter
Liver functionThe liver is not a filter
  • Liver is a factory for synthesis
    • Food digested/absorbed  portal vein
    • Raw materials  proteins, carbohydrates, fats
    • Disposition
      • Hepatic vein to heart  circulation
      • Waste to bile  stool
  • Liver function tests
    • Delivery: platelet count (down with hypersplenism)
    • Synthesis: INR, Albumin
    • Excretion: Bilirubin (conjugated)
fibrosis progression to symptoms

INR

Bilirubin

Platelets

Albumin

Fibrosis progression to symptoms

Cirrhosis

Symptoms

Imaging, Biopsy

traditional test ultrasound
Traditional test: Ultrasound
  • Ultrasound
    • Small, coarse (rough), nodular
    • Ascites
    • Lobar redistribution
    • Echogenic (fatty)
  • Limitations
    • Later cirrhosis
    • Tough to do in central obesity
    • Expertise of Radiologist/Technician
liver biopsy
Liver biopsy
  • Safety
    • 1/5: pain from bleed
    • 1/5,000-1/10,000
      • BLEED
      • Death
      • Pneumothorax etc.
  • Time
    • Hospital x hours
    • Results in weeks
  • Error
    • Inadequate sample
    • Inadequate Expertise
  • Additional information
    • Inflammation
    • Fat
occult cirrhosis can be uncovered by evaluation of unexplained thrombocytopenia
Occult cirrhosis can be uncovered by evaluation of unexplained thrombocytopenia
  • VA New York Harbor Health System 2008-2010
    • N=497 not known to have cirrhosis/liver disease
      • N=382 analyzed
      • N=112 assessed by GI or Hepatology
        • 62 finished evaluation, 31 (50%) have cirrhosis
          • 4 developed hepatoma
          • Hepatitis C, ALD, NAFLD
        • APRI 1.41 in cirrhotics, 0.64 in non-cirrhotics

E Weiss et al. ACG 2012, P1353

combined clinical tests apri fib 4
Combined Clinical Tests: APRI & FIB-4

ASTxULN x 100

Platelet count

  • Cirrhosis
    • Older individuals
    • Platelets fall
    • AST > ALT (alcohol)
  • Limitations
    • Must be calculated!
  • APRI
    • <0.5 is good
    • >1.5 is advanced
  • FIB-4
    • <1.45 is good
    • >2.35 is advanced

Age x AST

Platelet x ALT

fibrotest wikipedia or www torontoliver ca
FibrotestWikipedia or www.torontoliver.ca
  • Age
  • Gender
  • GGT
  • Bilirubin
    • May be indirect
  • a2-macroglobulin
  • Haptoglobin
    • May be down
  • Apo-Lipoprotein A1

L Castera et al. Gastroenterology 2005;128:343

fibrotest
Fibrotest

T Poynard et al. Comparative Hepatology 2004;3:8

fibroscan
Fibroscan
  • Accessing the liver
    • Obesity
    • Rib space
    • Air (lungs, gut)
  • Probe size
    • Small (S1 vs S2)
    • Medium*
    • Large
  • Time
    • 2.5-3 minutes/scan
  • Maintenance
    • 6-monthly calibration
  • Probe damage
    • Gel, cleaning
performance characteristics
Performance characteristics

APRI

ASTxULNx100

Platelet

Laurant Castera et al. Gastroenterology 2005;128:343

fibrosis in psoriatics a new users mtx n 24 b biologics n 15 c long term mtx n 10
Fibrosis in PsoriaticsA: New users MTX (N=24), B: Biologics (N=15), C: Long term MTX (N=10)

PIIINP = N-terminal propeptide of collagen type III ; HA = Hyaluronic Acid

J Chladek et al. J EurAcadDermatolVenerolepub Aug 2012

recommendations for methotrexate or imuran
Recommendations for Methotrexate or Imuran

Baseline

Monitoring

Labs

ALT, AST, ALP

Look for rising numbers over the first year that continue to go up rather than just fluctuate

CBC

Look for falling platelet count to < 150

Very concerned if Plts < 150 and falling by >15% over 2 years

  • History
    • Metabolic syndrome
    • Did you ever drink on a regular or daily basis?
    • Other history of liver disease
  • Labs
    • ALT, AST, ALP, CBC
      • Ultrasound if abnormal tests
        • Especially if Plts < 150
    • HBsAg
what to do for your cirrhotics
What to do for your cirrhotics
  • Plts < 150: suspect cirrhosis
  • Plts < 100: likely will have varices
  • Plts < 70: higher risk of renal failure (hepatorenal syndrome)
    • No NSAIDS (even with PPI)
    • Tylenol <3-4g/day is much safer
  • Coffee may be good
  • Alcohol in moderation may be good